آخـر مواضيع الملتقى

دعــــــاء

العودة  

كيفية تطبيق معايير المجلس المركزي ومراحل التقييم

ملتقى الجودة وسلامة المرضى
إضافة رد
  رقم المشاركة : [ 31 ]
قديم 04-29-2011, 06:37 PM
صحي نشط
 

تحسين الآداء will become famous soon enough
افتراضي

معايير التمريض التي تقييم بملفات التمريض
NR.2.PT1 Qualified, registered and experienced nursing director (BSN, Registered nurse by the Saudi Council for Health Specialty (SCFHS) with 5 years experience)
NR.13.PT1 Availability of trained infection control liaison nurse
NR.15.PT3 Clinical work assignments are based on nursing staff member credential and skills
NR.21.PT1 Delegation to non nursing staff assignments under supervision of registered nurse
NR.23.PT1 A qualified head nurse/nurse manager with 3 years experience at unit level , clearly stated in the Job de******ion
NR.24.PT1 A qualified charge nurse with 2 years experience at unit level within the area of practice, clearly stated in the Job de******ion
NR.25.PT1 A qualified Staff nurses with one year as a minimum experience in the area of specialty clearly stated in the Job de******ion
NR.28.PT1 Current job de******ions that are reviewed and updated at least every (3) years for every category of nursing staff
NR.28.PT2 Job de******ions are used for recruiting, evaluating, and appointing nursing staff.
NR.40.PT2 Evidence of Nursing competency assessment on medical equipment
NR.54.PT2 Evidence of nurses training on proper Patient restrain
NR.54.PT3 Evidence of nurses competency assessment on Patient restrain
NR.60.PT1 Evidence of Nursing Training on pain management
NR.61.PT1 ALL Nursing staff attends hospital orientation (sampled personnel files)
NR.62.PT2 Evidence of comprehensive Nursing Orientation for All new hires (including policies and systems, quality plan, infection control, fire and safety, CPR)
NR.63.PT1 Evidence of unit specific orientation program for All new hires
NR.63.PT2 Nursing competency assessment is documented in the personnel file
NR.64.PT2 Evidence of documentation of nursing education program (attendance record and personnel file)
NR.65.PT2 Evidence of nursing competency assessment (written test, return demonstration)
NR.65.PT3 Comprehensive nursing skills checklist with competencies (assessment& reassessment, medications, IV therapy, infection control, fall, oximetry, placement of tubes and catheters, sterile dressing, skin care, blood sugar testing, chemical spills, blood and blood products)
NR.66.PT1 Evidence of training of nursing staff about safety, security and medical equipment operation and maintenance
NR.67.PT1 Evidence of training of nursing staff on their role during disasters (Mock event).
NR.68.PT1 Evidence of annual nursing education on occupational hazards
من مواضيع : تحسين الآداء
تحسين الآداء غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 32 ]
قديم 04-29-2011, 06:43 PM
صحي نشط
 

تحسين الآداء will become famous soon enough
افتراضي معايير التمريض التي تقييم بمراجعة السجلات الطبية

معايير التمريض التي تقييم بمراجعة السجلات الطبية

NR.33.PT2 Nursing staff Documenting in the Medical Record
NR.41.PT2 Evidence of Implementation of nursing documentation
NR.42.PT2 Evidence of implementation of nursing assessment policy.
NR.43.PT2 Evidence of nursing implementation of Nursing reassessment
NR.44.PT2 Evidence of implementation of written plan of care (the care plan is interdisciplinary and is reviewed each shift or when significant changes occur)
NR.45.PT1 Adherence to preoperative preparation (Preoperative checklist contains evidence of proper ID process for the patients, type of operation/ surgeons name, site or surgery and marking, x-ray jacket for accompanying the patient to surgery, lab results, pre anesthesia sheet. History and physical, blood requirements).
NR.51.PT2 Evidence of compliance with telephone orders (sampled medical records)
NR.52.PT2 Evidence of compliance with Verbal orders policy (sampled medical records)
NR.53.PT2 Evidence of proper patient identification process (Two identifiers - Medical record number and patients name)
NR.53.PT3 Evidence of verification of patient identity by two hospital staff prior to blood drawing for cross match and prior to administration of blood
NR.54.PT4 Evidence for compliance with Patient restrain policy (physician order, assessment and re-assessment, protecting patient dignity, appropriate and timely intervention, other)
NR.54.PT6 Patients Restrains is documented in the medical record
NR.56.PT1 Evidence of implementation new born verification process at discharge
NR.57.PT3 Transfer information is documented in the medical record and other areas as appropriate
NR.58.PT1 Evidence of patient and family education at (discharge and referral )
NR.60.PT2 Evidence of Nursing competency on pain management
NR.60.PT4 Evidence of documentation of pain management in the medical record
من مواضيع : تحسين الآداء
تحسين الآداء غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 33 ]
قديم 04-29-2011, 06:59 PM
صحي نشط
 

تحسين الآداء will become famous soon enough
افتراضي معايير المختبر التي تقييم بالوثائق

معايير المختبر التي تقييم بالوثائق
LB.1.PT5 Evidence of adequate control of temperature and humidity (Log book)
LB.2.PT1 Written policies on Emergency Lab Services
LB.3.PT1 Availability of laboratory service guide explaining available tests, specimen requirement and TAT.
LB.4.PT1 Availability of updated and approved Lab organization structure with lab sections and staff categories identified under the director supervision.
LB.6.PT1 Written Lab competency program that ensures staff awareness of internal policies and procedures.
LB.7.PT1 The test procedure records should contain a heading related to accountability of test performance, supervision and interpretation
LB.8.PT1 Written policy on pipets precision and calibration
LB.8.PT2 Documented quality control procedure and results of the process for Pipets check. Pipets
LB.9.PT1 Documented quality control procedure and results of the process for for thermometers check (Temp charts and records thermometer certificate) Thermometers
LB.10.PT1 Temperature record for all temperature dependent equipment with defined acceptable ranges
LB.11.PT1 Written policy and procedures on corrective action when temperature exceeds acceptable range.
LB.11.PT2 Evidence of corrective action taken for fridge temperature when temperature exceeds acceptable range
LB.11.PT3 Evaluation of contents for adverse effects on refrigerated materials
LB.12.PT1 Documented quality control procedure and results of the process for Balances check and maintenance.
LB.13.PT1 Documented and scheduled quality control procedure and results of the process for Centrifuges check and maintenance.
LB.13.PT2 Documented quality control procedure and results of the process for all instrument check and maintenance.
LB.14.PT1 Written policy and procedures on unscheduled maintenance system.
LB.14.PT2 An accessible maintenance records near each instrument documenting the utilization of Quality Control chart, linearity limits and repairs.
LB.15.PT1 Written policy and procedures on Lab. Reagents handling and storage.
LB.16.PT1 Result reporting system is clear, acceptable and well defined utilizing the approved normal values with appropriate revision of out of range results. Handling use of published data for use when formal reference interval study is not possible or practical.
LB.17.PT1 Written policy on Laboratory stat and routine orders reporting time
LB.17.PT2 Evidence of All STAT test reporting within 1 hour.
LB.17.PT3 Evidence of compliance with TAT for routine test
LB.18.PT1 Written manual on specimen collection and transportation (methods for patient identification, patient preparation, specimen collection/labeling, preservation, storage, and condition for transportation).
LB.20.PT1 Written guidelines on specimen collection, transportation and sample preparation is distributed to physicians and paramedical staff/ includes cytology histology specimens.
LB.21.PT1 Written policy and procedures on specimen transportation and result reporting
LB.21.PT2 Documentation of selection process and certification of selected out sourced lab.
LB.21.PT3 List of test to be outsourced is available.
LB.22.PT1 Accessible and approved, current or reviewed (every 2 years) lab procedure manual.
LB.23.PT1 Written policy on Panic value reporting (name of persons providing and receiving the panic value results and time of the call).
LB.23.PT2 Evidence of staff compliance with Panic value reporting
LB.25.PT1 Written policy and procedures on blood donation, storage of blood and blood products.
LB.25.PT3 Evidence of patient consent for blood donation (signed consent form)
LB.26.PT1 Written policy and procedures on care of donor (Includes treating donor adverse reactions, necessary equipment for immediate care, confidentiality and privacy of donor selection criteria)
LB.27.PT1 Written policy and procedures on blood type/ Rh, cross match, antibody screening and Antibodies identification
LB.28.PT1 Written policy on screening any donated blood
LB.28.PT2 Written policy on tracking all blood units
LB.28.PT3 Evidence of tracking donated blood from screening, notification of donor, storage to disposition).
LB.29.PT1 Clear hospital policy on blood ordering and handling of shortage
LB.29.PT2 Written policy on proper identification of blood unit.
LB.31.PT1 Written policy on reporting all adverse transfusion reactions LB.31.PT2 Evidence of adverse transfusion reactions records revision by lab director and submission to blood utilization committee.
LB.32.PT1 Blood utilization and wastage reporting policy
LB.32.PT2 Record for blood utilization and wasting
LB.33.PT1 Blood bank Temperature dependent instrument/equipment must be continuously and strictly monitored utilizing the best method to ensure safe storage environment.
LB.33.PT4 If there is no continuous automated recording; temperatures are manually recorded at least every four (4) hours
LB.34.PT1 Blood bank Temperature dependent instrument/equipment alarm system must have a separate power source and is maintained periodically.
LB.35.PT1 Written Comprehensive, accessible and approved (by lab director) Histopathology and Cytopathology policy and procedures
LB.35.PT2 staff orientation Histopathology and Cytopathology staff under went orientation and training
LB.36.PT1 Written policy on sending All specimens removed from patients to the pathology.
LB.36.PT2 A lab director in agreement with the medical staff approved policy and records of exempted pathology specimens. Approved list of specimens exempted from microscopic examination is available.
LB.37.PT1 Evidence of reviewing the current cytological/histological material with the pertinent previous one.
LB.38.PT1 Evidence of reconciled disparities between the frozen section, cytology, or gross evaluation and final pathology diagnosis.
LB.39.PT1 Policy for assignment of pathologist to examine all gross specimens
LB.39.PT2 Evidence of pathologist examination of all gross specimen and retention of specimen not less than 1 month.
LB.40.PT1 Evidence of daily supervision of all stages of specimen processing and quality monitoring
LB.40.PT2 Evidence of daily review of the technical quality of histological preparations by the pathologist.
LB.41.PT1 Written policy on pathology reporting system.
LB.41.PT2 The pathology report is adequate, proper and approved by the histobathologist.
LB.42.PT1 Defined and monitored TAT for frozen section and routine histology and cytology specimen reports.
LB.43.PT1 Documentation of All intra-departmental and extra-departmental cases submitted for consultation
LB.44.PT1 Pathology records and materials retention policy (2-years for accession log records, 10-years for Paraffin blocks, Glass slides and reports, cytopathology and Histopathology Reports, and Fine needle aspiration glass slides, 5-years for Gynecologic and non-gynecologic glass slides)
LB.44.PT2 Evidence of lab compliance with the written policy
LB.45.PT1 Written policy and procedures on unsatisfactory gynecologic specimen
LB.45.PT2 Evidence that unsatisfactory gynecologic specimen and other gynecologic cytopathology results rate is documented and monitored by lab director.
LB.46.PT1 There is an appointed lab safety officer
LB.46.PT2 A written job de******ion for the Safety Officer.
LB.46.PT3 Lab safety officer is a member of the safety committee
LB.47.PT1 The lab safety officer ensures the lab compliance with the FMS standards
LB.48.PT1 Comprehensive lab safety manual approved by the laboratory director (include handling chemical hazards, chemical spills, chemicals list with manufacturer, lab accident documentation, reporting injuries, fire prevention and control safe handling of electrical equipment and wastage handling and disposal).
LB.49.PT1 Training on how to use fire extinguishers, checking of fire alarms, fire extinguishers is document review.
LB.50.PT1 Evidence of annual electrical checks (equipment are grounded and the outlets are checked for grounding)
LB.53.PT1 Written policy on the Proper disposal of sharp containers
LB.57.PT1 Evidence of Monitoring Formaldehyde and Xylene vapor concentrations at least once a year
LB.62.PT1 Plan to reduce or eliminate the usage of mercury in the lab if it is still in use
LB.63.PT1 Evidence of monitoring the condition and fit of the HEPA filters for air flow velocity and smoke patterns, and for output of UV lights.
LB.64.PT1 Evidence of monitoring fume hoods for the air flow velocity and smoke patterns at least once a year.
LB.65.PT1 Available and approved (by lab director) a lab quality management program
LB.67.PT1 Lab Quality indicators development and evaluation.
LB.67. PT2 Evidence of Incident report system
LB.67. PT3 Evidence of monitoring Turn around time for lab test
LB.67. PT4 Evidence of monitoring Specimen identification errors
LB.67. PT5 Evidence of monitoring corrected pathology reports.
LB.68.PT1 Lab incident and accident are part of QI program
LB.68.PT2 Evaluation of the lab incident and accident report to avoid recurrence.
LB.69.PT1 Availability of external quality assessment program (or split sample analysis with all problems identified by PT recognized and corrected)
LB.69.PT1 Evidence of problems identification recognition and correction.
LB.70.PT1 Evidence of documentation of all Quality Control results
LB.70.PT2 Detection and correction of analytic errors or uncertainness from each test and instrument
LB.70.PT3 Results of the control are recognized
LB.70.PT4 Results of the control corrective action taken
LB.70.PT5 Instruments function
LB.70.PT6 Temperature limits for procedures is clear in the procedure manual
LB.70.PT8 Periodic maintenance program for equipment
LB.70.PT9 Checking of tolerance limits
LB.70.PT10 Checking media for quality
LB.71.PT1 Written policy on Lab Infection Control
LB.71.PT3 Evidence of cooperation with IC department.
LB.76.PT1 All employees are vaccinated with (HBV) Hepatitis B Vaccine
LB.77.PT1 Written policy on safe handling of reagents
LB.80.PT1 Written policy on Dealing with tuberculosis specimens
LB.81.PT1 Written policy and procedures on Point of care (POC) testing in the lab and in the areas where POC Testing is performed
LB.81.PT2 Point Of Care Testing list all over the hospital.
LB.81.PT3 Point of care Quality Control /Quality Management program and documented evaluation
LB.82.PT1 Point Of Care Testing detection system for clerical and analytical error and correction (an appropriate person 24 hours/day for POCT concerns)
LB.82.PT2 Lab staff orientation, training, and competency testing.
LB.82.PT3 Lab staff orientation, training, and competency on Point Of Care Testing users
من مواضيع : تحسين الآداء
تحسين الآداء غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 34 ]
قديم 04-29-2011, 07:02 PM
صحي نشط
 

تحسين الآداء will become famous soon enough
افتراضي معايير المختبر التي تقييم بالمشاهدة

معايير المختبر التي تقييم بالمشاهدة

LB.60.PT8 Refrigerators and freezers approved for storage of flammable liquids are identified with a sign or label
LB.61.PT2 Precautionary signs are posted in the Lab section dealing with radioactive materials
LB.70.PT7 Expiration date on reagents
LB.71.PT2 Standard precaution are strictly followed.
LB.71.PT4 Gloves, masks, and eye, face shield, gowns, and aprons and lab coats are available and are worn as appropriate on lab sections
LB.71.PT5 Eating and drinking is prohibited
LB.73.PT1 Evidence of implementation of universal precaution for handling blood and body fluids.
LB.74.PT1 Availability of leak-proof containers
LB.74.PT2 All specimens of blood and body fluids are transported in leak-proof containers.
LB.75.PT1 Evidence of proper cleaning by housekeeping
LB.78.PT1 Availability of a Class II safety cabinet that is required when working with high infectious material
LB.79.PT1 Maintenance of Negative pressure in high infectious areas
LB.80.PT3 Availability of separate Laboratory for use in handling TB specimens
من مواضيع : تحسين الآداء
تحسين الآداء غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 35 ]
قديم 04-29-2011, 07:05 PM
صحي نشط
 

تحسين الآداء will become famous soon enough
افتراضي المعايير التي تقييم بالمقابلة مع العاملين بالمختبر

المعايير التي تقييم بالمقابلة مع العاملين بالمختبر

LB.2.PT2 Evidence of hematology lab working 24/7 (staff interview)
LB.2.PT3 Evidence of Biochemistry lab working 24/7 (staff interview)
LB.2.PT4 Evidence of Transfusion services working 24/7 (staff interview)
LB.3.PT2 Evidence of medical staff awareness of the Laboratory service guide.
LB.22.PT2 Evidence that All staff are aware of current lab manual and policies & procedures.
LB.35.PT3 Histopathology staff are aware of the content.
LB.48.PT2 Evidence of staff awareness of lab safety
LB.49.PT2 Staff are able to state what actions to take in the event of fire
LB.65.PT2 Lab staff are aware of lab quality management program
LB.80.PT4 Hoods and safety cabinets are monitored for efficiency
من مواضيع : تحسين الآداء
تحسين الآداء غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 36 ]
قديم 04-29-2011, 07:10 PM
صحي نشط
 

تحسين الآداء will become famous soon enough
افتراضي المعايير التي تقييم بمراجعة ملفات العاملين بالمختبر

المعايير التي تقييم بمراجعة ملفات العاملين بالمختبر

LB.4.PT2 Lab Director is a qualified pathologist or a qualified clinical scientist
LB.5.PT1 Job de******ions for all Lab Staff (Sampled personnel files)
LB.5.PT2 Documented lab staff orientation and training program
LB.6.PT2 An annually documented competency assessment of ALL staff (includes written evaluation of direct observation of test procedures)
LB.61.PT1 Evidence of staff training on handling and disposing of Radioactive materials
LB.66.PT1 Evidence of an assignment of Lab quality management officer to coordinate and implement the QM program.
LB.72.PT1 Lab staff are educated and trained on handling of infectious specimen, disinfection of work area, disposal of infectious material and clean up of leak or spill.
LB.80.PT2 Lab staff training program on TB safety precautions


معايير المختبر التي تقييم بمراجعة السجلات الطبية


LB.30.PT1Blood is ordered only by authorized physician
من مواضيع : تحسين الآداء
تحسين الآداء غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 37 ]
قديم 04-30-2011, 07:47 PM
افتراضي

الف شكر لكل من شارك بهذا الموضوع

بارك الله سعيكم وجعله الله علماً ينتفع به

واتمنى تفاعل الجميع لما للموضوع أهمية في تبادل الخبرات
من مواضيع : الكفاح
الكفاح غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 38 ]
قديم 07-16-2011, 05:52 PM
افتراضي

بعد اكمال الملفات للوثائق

يتم تحضير ملفات العاملين طبعاً هناك قائمة يتم تحضير ملفاتهم

كذلك جميع الأقسام لابد تكون ملفات العاملين بها جاهزة

طريقة ترتيب الملفات بناء على المطلوب حسب المرفقات للتحضير من المجلس المركزي لإعتماد المنشئات الصحية
من مواضيع : الكفاح
الكفاح غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 39 ]
قديم 11-26-2011, 10:35 PM
افتراضي

السلام عليكم ورحمة الله وبركاته

وردني سؤال من أحد الأخوان هذا نصه

معيار رقم 81 في المختبر point of care ماهو المقصود منه
هل المقصود منه ان يقوم التمريض بعمل جميع التحاليل التي تستخدم الشريط في القسم وعدم ارسالها الي المختبر ام المقصود فيه الحلات الطارئه كما فهمت من شرح المعيار


المقصود بهذا المعيار
اجهزة المختبر الموجودة خارج قسم المختبر
والتي يعمل عليها غير اخصائي المختبر مثل التمريض

وهذه الأجهزة مثل اجهزة قياس غازات الدم الشريانية
مثل تحليل ABG

طبعاً هذه الأجهزة تحتاج حصر بأماكن تواجدها مثل
موجود عدد2 جهاز قياس غازات الدم بوحدة العناية المركز المسئول عنه الممرض x
عدد 1 جهاز قياس غازات بالدم موجود بقسم الطوارئ المسئول عنه الممرض x
هذا مايخص تواجد الأجهزة خارج قسم المختبر ومن المسئول عنها

ايضاً لابد عمل دورات تدريبية للعاملين على هذه الأجهزة في تلك الأقسام المتواجد بها الأجهزة
وتعليمهم طريقة معايرة هذه الأجزة سواء في كل شفت ( نوبة) او مرة باليوم او مرتين

المعايرة هي عملية الكاليبريشن
calibration
هي عملية تهيئة الجهاز وعمل معادلة له في اول استعمال له
بعني لما تداوم في الصباح لابد تعمل معايرة للأجهزة قبل استخدامها حتى تظهر النتيجة صحيحة

maintenance
هي الصيانة هناك نوعان
الصيانة الوقائية ( الدورية ) مجدولة ولها تواريخ معينة لكل جهاز
أما النوع الثاني الصيانة عند تعطل الجهاز يعني فجائية

كذلك يعمل لهذه الأجهزة Quality Control كل فترة حسب المعايير وحسب البروتوكول المتبع لهذه الأجهزة
من مواضيع : الكفاح
الكفاح غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 40 ]
قديم 11-26-2011, 11:02 PM
افتراضي



رابط معايير المجلس المركزي

حيث الروابط السابقة لم تعد تعمل



CBAHI STANDARDS
من مواضيع : الكفاح
الكفاح غير متواجد حالياً   رد مع اقتباس
إضافة رد

مواقع النشر (المفضلة)

الكلمات الدليلية (Tags)
معايير, المجلس, المركزي, التقديم, تطبيق, ومراحل, كيفية


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